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Indiana State Board of Dental Examiners

Health Professions Bureau

402 W. Washington Street, Room 041

Indianapolis, Indiana 46204

INSTRUCTIONS FOR FILLING OUT ANY FORMS

Please read these instructions carefully before filling out any forms.

In compliance with IC 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be

processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become

public record. Your grade transcripts are confidential except in circumstances where their release is required by law, in which case you will be

notified.

Your Social Security Number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record

cannot be processed without it.

Prior to administering general anesthesia, deep sedation, or light parenteral conscious sedation, a dentist shall obtain from the board a permit

which authorizes the dentist to utilize the form of anesthesia or sedation desired.

A dentist holding a permit to administer general anesthesia and deep sedation will not be required to obtain a separate permit to administer light

parenteral conscious sedation.

APPLICANTS FOR A GENERAL ANESTHESIA-DEEP SEDATION PERMIT

(Which includes authorization to use light parenteral conscious sedation)

1. Complete the enclosed application for a permit.

2. Enclose a check or money order in the amount of $15.00 made payable to the Health Professions Bureau.

3. Submit satisfactory evidence of completion of educational and training requirements:

(a) a certificate of completion of the educational or training program signed by the dean of the board approved dental school

or director of the board approved anesthesiology or oral maxillofacial surgery residency from which the training was obtained; or

(b) an official transcript from the board approved dental school which clearly designates completion of the education or training.

4. (a) The same level of training is necessary for administration of both deep sedation and general anesthesia.

(b) The residency in anesthesiology or oral and maxillofacial surgery shall meet the following requirements:

(1) The training program must be full time and be a minimum of one (1) year in duration.

(2) The program shall be a joint cooperative effort between the training institution's department of anesthesiology and department of dentistry.

(3) Instruction in both didactic basic science and clinical procedures must be incorporated into the program. This instruction may

be given in a seminar or conference format, or may include formal courses.

(4) The anesthesiology residency or anesthesiology portion of the oral surgery residency shall include preanesthetic patient evaluation,

administration of anesthesia in the operating room on a daily scheduled basis, postanesthetic care and management, and emergency call.

(5) Training must include anesthetic management for ambulatory outpatient procedures and the use of inhalation and intravenous

sedation techniques.

(6) The program shall include instruction in pain and pain mechanisms; and shall include training in and successful completion of a course

in advanced cardiac life support.

5. Submit an affidavit that the practitioner's office meets the board's equipment requirements. You must submit a separate affidavit for each

office where you will administer anesthesia or sedation. (sample form attached)

6. Submit proof that you are trained in and have successfully completed a course in advanced cardiac life support or that you are certified as

an instructor in advanced cardiac life support.

7. Mail all required items to the Health Professions Bureau. (see address above)

APPLICANTS FOR A LIGHT PARENTERAL CONSCIOUS SEDATION PERMIT ONLY

1. Complete the enclosed application for a permit.

2. Enclose a check or money order in the amount of $15.00 made payable to the Health Professions Bureau.

3. Submit satisfactory evidence of completion of educational and training requirements:

(a) the applicant graduated from an approved dental school which included training in conscious sedation techniques at the

predoctoral level; or

(b) the applicant completed an intensive postdoctoral training program in the use of light parenteral conscious sedation.

4. Submit an affidavit that the practitioner's office meets the board's equipment requirements. You must submit a separate affidavit for each

office where you will administer light parenteral conscious sedation.

5. Submit proof that you are trained in and have successfully completed a course in advanced cardiac life support or that you are certified

as an instructor in advanced cardiac life support.

6. Mail all required items to the Health Professions Bureau. (see address above)

State Form 46159 (7-93)

Form 46159 - Instructions For Filling Out Any Forms - Indiana State Board Of Dental Examiners

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